AL KHAFJI NATIONAL HOSPITAL

Evidence Based Clinical Practice

Guidelines for the Management of
Severe Pre-Eclampsia
A Clinical Practice Guidelines Adopted from CPG Source:
American College of Obstetrics and Gynecologist,2019
Presented by:
Dr. Amro Sadakah
Consultant Obstetrician
Department Head, Obstetrics and Gynecology
 Prevalence
Hypertensive disorders of pregnancy constitute one of the
leading causes of maternal and perinatal mortality worldwide.
It has been estimated that preeclampsia complicates 2–8% of
pregnancies globally (Steegers et al, 2010). Although maternal
mortality is much lower in high-income countries than in
developing countries, 16% of maternal deaths can be
attributed to hypertensive disorders (Steegers et al., 2010 and
Khan et al, 2006).

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 Why Is Pre-Eclampsia among
Pregnant Women a Concern?
This complication is costly: one study reported that in
2012 in the United States, the estimated cost of
preeclampsia within the first 12 months of delivery
was $2.18 billion ($1.03 billion for women and $1.15
billion for infants), which was disproportionately
borne by premature births (Stevens et al., 2017).

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Based on the OB-Gyne CPG Subcommittee they selected to work on this guidelines
based on the criteria stipulated below and they prioritized it to come up with and
adopted best practice and guidelines.

POST PARTUM
CRITERIA PRE ECLAMPSIA CORD PROLAPSE
HEMORRHAGE
High Risk Impact of Disease/Condition 4 4 4
Disease/Condition has Hight Individual 4 4 4
Cost
High Volume of Cases 4 4 4
Priority Areas in Morbidity and Mortality 4 3 3
Availability of High Volume of Evidences 4 4 4
SUM 4 3.8 3.8

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Objectives in Adapting a CPG for
Severe Pre Eclampsia
To look for an evidence based CPG to effectively management
pre-eclampsia patient to;
 Standardize the management
 Improve clinical results and patient outcomes.
 Improve Utilization by improving length of hospital stay, decreasing
overall cost, etc.

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 KNH INSTITUTIONAL
PROTOCOL BASED ON
THE ADOPTED CPG

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 Diagnosis and
Admission Criteria

In patients with preeclampsia, the addition with

severe features is used when any of the features
listed in Table.
Patients with suspected preeclampsia should be
admitted to the hospital to confirm the diagnosis,
assess severity, monitor maternal and fetal
status, and initiate supportive therapy or perform
delivery.

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 Management/Treatment Guide
FLUID BALANCE
 Increased risk of fluid overload and pulmonary oedema that exists secondary to reduced colloid oncotic pressure
 No evidence that colloid replacement in pre-eclampsia is superior to crystalloid except perhaps in cases where there is renal or
cardiopulmonary compromise

BLOOD PRESSURE CONTROL

 The goal of antihypertensive treatment is prevention of potential complications such as stroke (intracerebral abruption hemorrhage), cardiac
failure and placental
 The threshold for treatment is a diastolic blood pressure (DBP) >110 mmHg and/or systolic blood pressure (SSP) >160 mmHg.
 Slow but steady reduction of SSP to 140-160 mmHg and DBP to 80-110 mmHg with constant fetal monitoring (fetal heart rate) is required
 Drugs commonly used in the acute setting (or blood pressure control include
 Labetalol may be administered in bolus form (20-40 mg)I.V. to a maximum of 220 mg with or without a continuous infusion (1-2 mg/min
 Hydralazine can be given in 5mg aliquots every 20 minutes to a maximum of 40 mg.
 Angiotensin-converting enzyme (ACE) inhibitors and angiotensin -2 receptor blockers are both CONTRAINDICATED in the acute
management of pre-eclampsia secondary to their potential to cause neonatal renal failure and also secondary to their relatively delayed onset
of action (1-4 hours)

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 Management/Treatment Guide
SEIZURE PROPHYLAXIS
 A standard prophylactic and therapeutic MgS04 regime includes:
 Loading dose of 4-6 g over 15 min intravenously
 Maintenance infusion of 1-2 g/hr
 Target serum concentration of magnesium: 2-3.5 mmol/L (4.8-8.4 mg/dL)
 Monitoring of magnesium levels

HELP SYNDROME
o Laboratory investigations and results consistent with HELLP include:
 Peripheral blood smear
 Presence of burr cells and/or schistocytes indicates microangiopathic hemolytic anemia
 Reduced serum haptoglobin levels, elevated serum bilirubin and LDH >600 lUlL are consistent with hemolysis
 Presence of thrombocytopenia (Platelet count 70 IU/L)
o A differential diagnosis for HELLPsyndrome should include:
 Acute fatty liver of pregnancy
 Acute hepatitis

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 Implementation Strategies
 Orientation to disseminate information
 Multidisciplinary meeting with other health
professionals (nurses, laboratory technicians)
 Competency Assessment
 Continuous Compliance Verification

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 Compliance Audit with the
Prescribed Protocol/Guidelines
Patient record conform to KNH standards

Relevant checklist /form completed & attached to the file

Patient progress during episode of care documented in the file timely & signed

Required medication given according to protocol /Guideline& documented in medication sheet with: date, dosage, frequency & duration

Required laboratory and/or other diagnostics (initial &subsequent)

Patient assessment done within time frame according to protocol/Guideline

Identification information

0 20 40 60 80 100 120

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 Performance Measure
of the Guidelines
120
LIVER FUNCTION TEST PERFORMED AMONG PRE
ECLAMPSIA PATIENTS
100
Rationale: Amongst pre-eclampsia patient, abnormal liver function
tests were associated with greater more maternal complications. This
80 indicator assesses the compliance of health Practioner regarding the
importance of the major tool for assessing the severity of disease &
early detection of related complication which may improve patient
60 Percentage
management and outcomes.
Target

40 Target: 100%

Based on the aggregated data it has shown that diagnosed PRE

20 ECLAMPSIA patients who were admitted has shown that timely
and appropriate diagnostic assessment was done which prevented
any development of maternal complications.
0
2020 Jan to June July to Nov

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